Pregnant and postpartum women’s experiences of the indirect impacts of the COVID-19 pandemic in high-income countries: a qualitative evidence synthesis

Background Pregnant and postpartum women’s experiences of the COVID-19 pandemic, as well as the emotional and psychosocial impact of COVID-19 on perinatal health, has been well-documented across high-income countries. Increased anxiety and fear, isolation, as well as a disrupted pregnancy and postnatal period are widely described in many studies. The aim of this study was to explore, describe and synthesise studies that addressed the experiences of pregnant and postpartum women in high-income countries during the first two years of the pandemic. Methods A qualitative evidence synthesis of studies relating to women’s experiences in high-income countries during the pandemic were included. Two reviewers extracted the data using a thematic synthesis approach and NVivo 20 software. The GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in review findings. Results Sixty-eight studies were eligible and subjected to a sampling framework to ensure data richness. In total, 36 sampled studies contributed to the development of themes, sub-themes and review findings. There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen review findings were developed under these themes with high to moderate confidence according to the GRADE-CERQual assessment. Conclusions The findings from this synthesis offer different strategies for practice and policy makers to better support women, babies and their families in future emergency responses. These strategies include optimising care delivery, enhancing communication, and supporting social and mental wellbeing. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-024-06439-6.


Background
As of February 2024 SARS-CoV-2 has infected over 774 million people, and 7 million deaths have been attributed to coronavirus  infection [1].Maternal and newborn health services are essential for pregnant and postpartum women, and the COVID-19 pandemic significantly altered provision and access to routine care.Reduced services, limited face-to-face care, transition to virtual and remote care, and limited access to maternity care providers were commonly cited as barriers to accessing quality care by pregnant and postpartum women [2][3][4][5][6].Additionally, reduced lengths of stay within hospitals and restrictions on support people imposed by health facilities have impacted women receiving care and placed an additional burden on nursing and midwifery staff [7][8][9].This had significant impacts on pregnant and postpartum women's emotional and psychosocial wellbeing.
Pregnant women and their babies were at an increased risk of adverse effects if she contracted SARS-CoV-2 [10,11].The direct impacts of the COVID-19 pandemic were largely focused on the clinical manifestations of SARS-CoV-2 such as symptoms, risk factors, management and treatment, as well as adverse maternal and newborn outcomes [12][13][14][15].However, at a wider level, the impacts of policy changes, health system reforms and changes to maternity care services indirectly affected the provision of care for all women giving birth over this time period.Women's experiences of the transition from pregnancy to motherhood were also impacted.For example, in many countries, pregnant women were encouraged to homestay at home, receive care through telehealth rather than face-to-face and reduce face-to-face education [16,17].Isolation from family, friends and peers has negatively impacted women's mental health, with increased levels of anxiety, depression and stress globally [18][19][20][21].
Since the beginning of the pandemic, there has been a plethora of qualitative studies on women's experiences [19,[22][23][24][25][26] -the significant volume of papers highlights the need for a clear synthesis.Reviews of qualitative evidence have reported pregnant women's experiences of social support [27], as well as highlighting the challenges they faced as they embraced motherhood during the pandemic [28].Collating the evidence in a systematic and transparent manner will allow policymakers to consider the indirect implications of public health restrictions on the physical, emotional, and psychosocial health and wellbeing of pregnant and postpartum women.
Qualitative evidence synthesis (QES) is an approach that can systematically collate qualitative data in a transparent manner to inform policy and practice [29].Findings from a QES can enable a richer interpretation of a particular phenomenon and enable a greater understanding of individual experiences, views and beliefs [30].
This QES aimed to explore, describe and synthesise the experiences of pregnant and postpartum women living in high-income countries during the first two years of the COVID-19 pandemic.This research method allows a deeper understanding of their views and experiences during this time.It also facilitates identification of areas of improvement for maternity care services, to ensure high-quality care is available at all times.

Methods
A QES was undertaken to identify, evaluate and summarise findings from qualitative studies providing a cohesive and transparent documentation of the contextual variations, stakeholder preferences and experiences to ultimately influence policy and practice [31,32].This type of synthesis integrates diverse perspectives, which is needed to capture the complexity of the indirect impacts of the COVID-19 pandemic on pregnant and postpartum women's experiences.This QES was structured to include findings from qualitative studies, as well as qualitative findings from mixed-methods studies.Emphasis was placed on including different types of qualitative evidence that can potentially enrich a synthesis, such as narrative data from qualitative components of mixedmethods studies or free-text from questionnaires [29].
We followed the relevant Cochrane guidelines [29] and used the "Enhancing transparency in reporting the synthesis of qualitative research" (ENTREQ) statement to guide our approach and reporting (Supplementary 1, S1) [33].In addition, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting the different phases of identifying studies was used as recommended by the ENTREQ statement (S2) [34].The protocol and systematic review were not registered.

Eligibility criteria
We defined "indirect impacts of the pandemic on women", to mean the impact of regulations, recommendations and public health measures enforced by governments as a response to the COVID-19 pandemic had on pregnant and postpartum women and their newborns.We adopted the World Health Organization's definition of the postpartum period beginning immediately after birth of the baby and extending to six weeks (42 days) after birth [35].
Participants within these studies were those who were pregnant or within the postpartum period, of childbearing age (15-49 years), and received any type of maternity care during the COVID-19 pandemic.Studies of women with pre-existing comorbidities were also eligible, as well as those focused on migrants, refugee populations or ethnic minority groups.To facilitate exploration of findings from women of diverse backgrounds we have used the term 'culturally and linguistically diverse (CALD) populations' .We focussed on women living in high-income countries (HICs).Studies were included if they were conducted in countries listed in the Organisation for Economic Co-operation and Development (OECD) [36] and Human Development Index (HDI) list of "Very high human development" list [37].This allowed for similar contexts and countries to be compared.
Eligible study designs were those that addressed the indirect impact of COVID-19 using qualitative methodologies, including phenomenology, ethnography, grounded theory studies and case studies.We also included any study that obtained data through qualitative methods for data collection such as, interviews, focus groups, online forums and document analysis.
The decision to limit the eligibility based on year of publication, to only include studies published in the first two years of the COVID-19 pandemic (1 st Jan 2020 -1 st Jan 2022) was to emphasise the impact of the stricter restrictions and lockdowns during this time period.Globally, public health measures to reduce spread and transmission included, mandatory quarantine, limiting movement, lockdowns, closure of schools and workplaces and shielding of vulnerable populations.These measures were significantly harsher during the first two years and subsequently relaxed as vaccine roll-outs occurred and infection rates began to decline [38,39].The Oxford Coronavirus Government Response Tracker reported a stringency index which reiterates the trend of harsher restrictions implemented by governments throughout 2020-2022 time period and reflects the gradual decline after this date [40].

Study selection and sampling framework
Two review authors (AT, AB) independently screened titles, abstracts and full texts for inclusion, with any conflicts resolved by discussion or consulting a third author.Reasons for exclusion are described within PRISMA flowchart (Fig. 1).Sixty-eight studies were included following full-text review.The Cochrane guidelines for QES highlight that for reviews with large amounts of primary studies (50 or more) can result in a high volume of data, which can threaten quality of the synthesis.In such situations, a sampling framework can enhance the quality and diversity of the papers and ensure the number of studies and amount of data are manageable [42][43][44].A QES worked example by Ames et al., 2019 was used as a guide to develop the sampling framework for data richness [45].Two independent reviewers scored included studies from 1 to 5 based on the criteria outlined in Table 1, to ensure that the sampling framework was reliable and replicable.Any conflicts were resolved by discussion, or a third review author was consulted.Studies with a score ≥4 were included for data extraction and are referred to as 'sampled' studies (S4).

Quality assessment
The Critically Appraisal Skills Program (CASP) tool for qualitative research was used by two independent review authors (AT, AB) to assess methodological limitations of sampled studies (S5) [46].Any disagreements were resolved through discussion, or when required, a third review author was consulted.Sampled studies were graded as no or very minor, minor, moderate or severe concerns with methodological limitations.

Data extraction and synthesis
A "Characteristics of sampled studies" table was created in Excel and details are reported in Table 2. Two independent reviewers familiarised themselves with the sampled studies and extracted key themes using Braun and Clarke's reflexive approach to inductive and deductive thematic analysis [47].Data were managed using NVivo 20 [48].This was an iterative process as many of the themes and sub-themes overlapped and were relevant in many aspects throughout the perinatal period (Table 3).The findings were developed iteratively, and periodically shared with the broader team to evolve our interpretation.Any quotes taken from studies were selected as they reiterated findings, and provided additional depth and meaning to review findings.
Extracted data were populated into two tables for analysis.The first table collated quotes and author interpretations of findings (S6), whilst the second table summarised these into review findings (Table 4).

Assessment of confidence in the review findings (GRADE-CERQual)
The GRADE-CERQual tool assesses the confidence in review findings from qualitative evidence syntheses [83].Lewin et al., 2018 state that that "the approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation" [83].The GRADE-CERQual Interactive Summary of Qualitative Findings (iSoQ) online platform was used to manage and assess confidence in review findings [84].
Confidence in review findings was determined based on four criteria: methodological limitations, coherence, adequacy and relevance [83].For each criterion, review authors determined if there were no or very minor, minor, moderate or serious concerns.An overall GRADE-CER-Qual assessment of confidence was placed on the findings, levels included: high, moderate, low and very low confidence.Review findings are considered at the highest confidence level and downgraded as there are greater concerns for each individual criterion (Table 4).This process was conducted by two authors, with any disagreements resolved through discussion and consulting other authors.

Managing our own reflexivity
Throughout the conceptualisation, data collection and analytical process, the authors considered their own individual views and beliefs about maternity care during the COVID-19 pandemic.As clinicians and researchers working on maternity care (including during the pandemic), we recognised that the COVID-19 period impacted indirectly on women and babies, including their experiences of care, their own anxieties and worries.We are public health professionals with diverse backgrounds including nursing and midwifery, maternal and newborn health, epidemiology and qualitative health research.We met regularly, both to explore the findings and the processes but also to ensure that we separated our individual experiences and beliefs on the interpretation of the analysis and the findings.Employing a systematic and transparent approach to the analytical process, such as including reflection notes after analysing each sampled paper, facilitated collaborative discussions, ensure objectivity and reduced the impact of personal biases.

Results
A total of 36 studies contributed to the synthesis of qualitative evidence to understand pregnant and postpartum women's experiences during the first two years of the pandemic.There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic.Seventeen sub-themes were developed within these 6 themes and illustrative quotes are presented in Table 3 to demonstrate theme development.Themes were categorised to differentiate major disruptors to the pregnancy and postpartum period and sub-themes aimed to categorise the indirect impacts that occurred within the major themes.
Studies were conducted across nine countries, almost one-third (N=10/36, 28%) of studies published from the UK, Canada (N=7) and the USA (N=7) (Table 2).Country-specific responses to the pandemic largely included border closures, mandatory lockdowns and restrictions on movement; it is interesting to note that Sweden did not mandate this but instead enforced social distancing practices [68].Additionally, some studies reported on a specific sub-population of pregnant and postpartum women, for example women from ethnic minority groups, those with pre-existing comorbidities, and those who were COVID-19 positive.Some studies also included results from women with babies who were greater than 6 months of age, and any findings directly from these participants were omitted from analysis where possible.
The number of participants in studies that conducted interviews ranged from 3 to 84, and studies using qualitative data from open-ended questions or survey data included responses from 16 to 4,611 participants.Where demographic data were available, approximately 1,192 women were primiparous (having their first baby) and approximately 8,017 women were surveyed or    Ireland [65] Qualitative study Aim: to understand the lived experience of pregnancy during the pandemic and the effects on the women's home life and social support system as well as learn from the effects that the hospital restrictions and measures had on women and their families.
Pregnant women

Breastfeeding challenges and triumphs
Breastfeeding infants during the pandemic had its own set of challenges and triumphs.For women who were struggling to establish breastfeeding and needed additional support, this was limited due to limited face-toface consultations.Women able to establish a breastfeeding routine described the lockdown and public health measures as a blessing in disguise as they had more undisrupted time to bond with their babies and were able to feed on demand.

High confidence
No The policies implemented limiting support people and partners throughout the perinatal period were described by women as unfair, anxiety and stress provoking, and traumatic.Women expressed their sadness and grief in partners missing milestones throughout pregnancy, as well as missing their advocators and support in labour and childbirth.On the postnatal ward, midwifery support was available, described as both lovely for mothers who coped well, and lacking compassion for mothers who felt minimally supported.Available support was appreciated but it was not the same as having their partners.

High confidence
No

Desiring connection with family and friends
Women felt sadness and heartbreak that their family and friends were not able to be physically present during their pregnancy and early postnatal period.They desired and needed practical support from their families and friends, for their mental health, physical wellbeing and as carers for older children.Postnatal women felt they were an afterthought in the government's plan to return to a COVID-safe society.

High confidence
No  of babies or studied specific subpopulations of women).[1-3, 7, 9-12, 15, 16, 18, 19, 21-28, 31, 33-36] 4.2.Feeling lonely and isolated Social isolation from family, friends, peers and society placed a burden on the mental health of pregnant and postpartum women.The increased sense of loneliness and isolation, and the inability to see or meet with family and friends was believed to increase depression in women.
The inability to receive adequate supports from care providers, further exacerbated the isolation women felt and had an impact on their physical wellbeing.Some described this experience as being forgotten or abandoned by the health care system.  of women or focused on different responses to the pandemic).[1, 2, 5-7, 11, 13, 14, 16, 19-24, 26, 29-31, 33-36] 7. Being resilient and optimistic 6.1.Self-help strategies to overcome challenges of the pandemic Women described having resilience and optimism in their reactions to public health measures and challenges during the pandemic.Women highlighted the need be conscious of and take care of their mental health and made active decisions to protect this.Women commented on their need to be advocates, encouraging other women to speak up to ensure they were receiving the best care for themselves and their newborns.Different coping strategies were used to ensure women preserved their mental and physical wellbeing.[ 1-3, 5, 7, 11, 12, 15, 18-21, 23-27, 31, 33, 35, 36]

Assessment of confidence Explanation of GRADE-CERQual Assessment
Reference ID #

Making the most out of the positive encounters
Despite the challenges of the pandemic, women found silver linings throughout the perinatal period.
Adherence to public health restrictions meant women had fewer social obligations allowing them to settle into their role as a mother and establish routines with their newborn.Fewer disruptions allowed families time to bond with the newborn and establish successful breastfeeding.For some, health services were described as a peaceful place to be.interviewed postpartum.Sampled studies were generally of high quality and assessment of methodological limitations indicated that 29 studies were assigned "no or very minor concerns", six studies were assigned "minor concerns", and one study was assigned "moderate concerns".When available, quotes obtained from studies have included additional demographic data.Factors included pregnant or postpartum status at time of data collection, parity and geographical location.

Theme 1: Dealing with public health restrictions
The rapid introduction of public health restrictions has had adverse effects on mental health, social isolation, and the pregnancy experience.Women had to navigate these restrictions and adapt accordingly, realising quickly that their pregnancy and postpartum experience was going to be very different from their expectations.

Sub-theme 1.1. Limited support networks from health care system and providers (High confidence)
Support networks were limited.Women felt that they were "on their own", "unimportant or irrelevant" or treated as "second class citizens" after birth, because of a lack of physical supports from healthcare providers [51, 60-62, 70, 72, 74].Limited or no access to physical and social support networks was commonly cited as a reason for deteriorating mental health.

Sub-theme 1.2. Balancing exposure risk and need for healthy behaviours (High confidence)
Women balanced COVID-19 exposure risks by shielding, either because of health providers recommendations [16,69] or because they felt it was needed to protect their baby [50,68,71,77,81].Women delayed or postponed antenatal appointments [50,57,69,72,82], opted for induction of labour [74], or waited until labour was quite advanced before attending hospital [60,61,77].These decisions were due to pandemic-induced fear, and the perceived risk of infection in a high-risk environment such as the hospital [16,56,80].

Sub-theme 1.3: Missing out on social opportunities (High confidence)
Women felt sad, unseen and heartbroken that they were not able to have social opportunities, especially sharing their newborns with family and friends [9,54,56,61,66,70,71,75,76].On postnatal wards, women with older children were disappointed that their nuclear families could not visit and bond with their newborn in the early postpartum period [56,59,80,82].While this was disappointing for many, one woman described still feeling well-supported, "we were supposed to have a baby shower, the weekend after everything shut down … definitely got a lot of gifts in the mail and people who drop things off ….
[we] feel like even though he's being born in this super crazy time and he doesn't necessarily get to meet people in person, that they are excited about him and want to support us" (USA) [52].Primiparous women felt that they missed the opportunity to share many "firsts" with extended families -one woman said, "this is my family's first grandchild so it just breaks my heart they will miss her whole babyhood" (postpartum, Canada) [64].

Sub-theme 1.4: Breastfeeding challenges and triumphs (High confidence)
Women that struggled with the lack of support around breastfeeding said, "when it came time for breastfeeding, I had no idea what to do or any challenges that could come.There were so, so, so many questions and I felt so confused during everything" (postpartum, primiparous, UK) [60].Lactation consultations through virtual remote care was considered inadequate by most women [51,66,71,73,75], especially when practical hands-on education and assistance was needed [51,53,72,77].These challenges led some women to cease breastfeeding early [51,62,73].Conversely, public health restrictions enforcing women to stay at home allowed some women to practice responsive breastfeeding, without concern for social obligations or visitors [51,62,64,71,75,79].Some women valued this flexibility -"there's no right or wrong way.You know, at the end of the day the ultimate goal is that my baby needs to be fed.…you know, feed him breast milk, breast milk, or formula.He's fed.He's happy.Sweet.That's done.Job done!The important thing is actually [to] be kind to yourself, you know?" (postpartum, primiparous, UK) [62].
Challenges and triumphs were felt by both multiparous and primiparous women [51].The difference between experienced and first-time mothers was stark in some studies, highlighted by multiparous women who felt 'knowledgeable' and 'had the experience' , and sharing empathetic messages towards primiparous women with limited breastfeeding support [62,78].However, the lack of face-to-face breastfeeding support meant that first-time mothers and experienced mothers also faced hardships.As one mother recounts her sadness: "I had virtual appointments [with lactation consultants], which I found totally useless… I was devastated that it wasn't working with [the new baby] because it was something I was really looking forward to" (postpartum, multiparous, Canada) [73].

Theme 2: Navigating changing health policies
The ever-changing nature of the pandemic created periods of uncertainty.Women and their families were expected to accept and adapt to changing health policies which directly impacted their antenatal, labour and birth and postnatal experiences.

Sub-theme 2.1: A birthing experience filled with uncertainty and unknowns (High confidence)
Many women reported that, given the constantly changing policies, they were unsure what to expect for their labour and birth [9,49,60,75,77].Limitations included not being able to have a water birth, use a bath or the shower, access nitrous oxide gas during labour [49,74,82] and others could not have their desired support people present [60,77].In some cases, women opted for medicalised interventions to retain a sense of control -choosing a caesarean birth to ensure their partner was present at birth [60,74].Women struggled with the prospect of early discharge, lacking confidence and fearing reduced support at home, with some feeling pushed out of the hospital [49,53,60,74].Some women chose to leave hospital early due to the lack of support or poor experiences while in hospital [60].Conversely, some women welcomed early discharge, wanting to be away from the hospital and to be reunited with family members [62,80].Women who tested positive to COVID-19 early in the pandemic described additional challenges, such as a lack of certainty on how care was going to be managed [77].They felt this restricted their autonomy over their labour and birth choices.

Sub-theme 2.2: Reduced support and partner presence healthcare settings (High confidence)
Due to the public health restrictions in hospitals, women often missed having their partner and family supports [16,49,57,66,71].For example, "one of my coping mechanisms is having my partner there to hear the same things I am hearing because I kind of shut down sometimes when I get too upset.It's always good to have that second person listening… and walking out with strength of unity" (pregnant, primiparous, Australia) [49].The inability for some women to have their partners present negatively impacted women's birthing experience [53,70,79,80], confidence on the postnatal ward and many expressed the sense of being "robbed of this experience" (pregnant, UK) [75].

Sub-theme 2.3: Transitioning to telehealth, virtual and remote care (Moderate confidence)
Public health restrictions limited face-to-face health care appointments with a maternity care provider [54].Negative telehealth experiences were expressed predominantly by first-time mothers [71], with many saying, "over the phone just doesn't do it… you don't get to look into somebody's eyes and to trust them and for them to say, you're okay" (postpartum, Ireland), adding to their anxieties.This was felt similarly by CALD women as there was a disconnect with health care providers using virtual methods and this was exacerbated for women who were not able to access interpreters [80].Positive encounters with telehealth were associated with the increased accessibility to health services and generally preferred by multiparous women [54,65,68].Whilst many were glad that telehealth services were available, this woman highlighted the inequities, "I think I would question the accessibility of that.Not everyone has a smartphone and expecting people to be able to receive a video call is not necessarily the most inclusive thing" (postpartum, primiparous, UK) [77] indicating that some women may have fallen through the gaps of maternity care.

Sub-theme 2.4: Barriers to accessing health services (High confidence)
The closure of so-called non-essential services, such as, physiotherapists, chiropractors, pools and gyms indirectly impacted women [66,74].This often increased women's anxiety, stress, feelings of helplessness and frustration [16,54,60,74] and incidence of postnatal depression [82].This also limited opportunities to receive reassurance from healthcare providers, reducing women's confidence [49,71,72,77].Typically, women accessed networks for information and support, such as, family and friends with midwifery clinical expertise, or referred to recent pregnancy experience [52,68,75,79].Women had to advocate strongly for physical assessments for themselves and their newborns [74].
Additionally, women from CALD populations were challenged in accessing culturally appropriate care with changes to interpretation services, "it creates like a…a gap in communication where if something you express is not clearly understood so maybe they could be left with some misinterpretation" (UK) [63].Another example of the inequities faced by CALD women was expressed by this woman who did not receive interpretation services during appointments, "sometimes they explained things to me by using signs and I understand a little English but it's hard to understand medical terms and they didn't use an interpreter for this" (postpartum, multiparous, Canada) [80].

Theme 3: Adapting to alternative ways of receiving social support
Support networks, such as, family and friends, peer support groups (e.g.mother's groups), and formal support from maternity care providers provide the foundation for a healthy and positive pregnancy and postpartum period.The COVID-19 pandemic forced women to adapt and seek support in different ways.

Sub-theme 3.1: Accessing support through different avenues (Moderate confidence)
Support from family and friends was accessed in different ways, for example, utilising video call technologies to be able to see faces helped with the grief of not being able to be present [16].Women who were able to establish pregnancy and mother's groups during the pandemic were grateful that they had these supports.Alternatively, women created or sought support through online social media platforms [61,68,70,81], to share a sense of camaraderie that they were not alone in their experiences [52,77].In these forums, women shared information about COVID-19 developments, updates to hospital policies, and utilised others as sounding boards for advice.Some women reported greater support from partners who had transitioned to working from home [51,62,64,66,75].Although virtual technologies allowed women to bridge the gap of social distancing, they wanted the physical connection with others.

Sub-theme 3.2: Desiring connection with family and friends (High confidence)
Women felt they needed intergenerational support to raise their newborns, and this was especially important during difficult times.Many had planned for parents to come and support them [81], as they believed that, "the older generation have more experience on what babies need or what they feel… with my other two [children]… they knew exactly what would make them feel better" (pregnant, multigravida, Australia) [49].Some women struggled without the additional support, the lack of sleep impeded their physical wellbeing [61,73,75], and the isolation from family impacted their mental health [9,49,56,60,61,73].In some cases, women were able to "quarantine with family", providing women with a "strong support network" (postpartum, Canada) as they transitioned into motherhood [59].Gradually, as public health restrictions eased, women from the UK felt government responses did not consider new mothers and babies and they called for "social bubbles" for families to receive the additional support [62,72].The loss of informal support networks was apparent for some CALD women.As this woman said, "it was really hard during COVID.In Syria I had my family… but to give birth here with no one with me?!I needed someone with me, my neighbours, my friends… I felt like I was drowning" (postpartum, multiparous, Canada) [80].

Theme 4: Dealing with impacts on their own mental health
The COVID-19 pandemic placed a significant toll on pregnant and postpartum women's mental health at all stages of the pandemic.Public health strategies failed to include protective measures for mental health, as such many women reported increased levels of fear, anxiety, stress, loneliness and depression.

Sub-theme 4.1: Managing anxiety due to virus-related fears and concerns (Moderate confidence)
Women often experienced anxiety exacerbated by the pandemic, for example, "as a new mom you are already so nervous, so adding a pandemic to that pile of anxiety and worry" (postpartum, Canada) [70].This was related to possibility of infection, particularly in hospital and healthcare settings [9,56,57,69,82], and the need to protect their unborn or newborn baby [50,72,80].Some faced additional challenges as migrants from another country, "I found it very hard when you're coming to the country without knowing anyone and the coronavirus, lockdown was very difficult, I was very depressed.I was very anxious… I feel worried a lot" (UK) [63].

Sub-theme 4.2: Feeling lonely and isolated (High confidence)
Loneliness and isolation were commonly reported as women faced motherhood alone without their usual support systems.One woman said, "it was quite sad that I couldn't even share my pregnancy experience with anyone, and I feel like I missed out" (postpartum, Australia) [54].Feelings of loneliness was especially felt by mothers who were not able to have their partners present during birth or postnatally [61].Women were not able to build supportive peer networks in their antenatal and postnatal periods [49, 62, 73-75, 78, 81], with one woman saying, "there's nothing like just meeting people or, just naturally building friendships when you go to baby groups" (postpartum, multiparous, UK) [62] emphasising the importance of developing social relationships.Cancellation of appointments and lack of face-to-face care added to feelings of "abandonment" and "being forgotten" [9,60,62,70,72,73].

Theme 5: Managing new and changing information
Due to the novelty of COVID-19 and lack of information about adverse effects, maternity care services had to rapidly adapt as new data came to light.Women described the need to search, access and filter useful information, a process which was challenging for many.

Sub-theme 5.1: Constantly changing advice and information (High confidence)
The constantly changing advice was distressing [82].These changes meant a lot of uncertainty, one woman said, "at 34 weeks I had a telephone appointment and I tried to ask what the changes in hospitals were, because of COVID and talk about the birth plan.She basically said, 'everything is changing so quickly there is no point in us even talking about that now.Wait until your next appointment'" (postpartum, primiparous, UK) [77].This limited women's ability to adequately plan and prepare for the birth.Some women described following the updates from government officials and hospitals overwhelming [66].As restrictions eased, women described the frustrations they had with the slow adaptations by health services, "when I got to the hospital, they didn't know about the restrictions having been lifted … That was really frustrating because I was like why?Why does this hospital not know?"(Australia) [82] and the differences between health services, "restrictions have still not been lifted in 'Hospital A' whereas they have been eased in both 'Hospital B' and 'Hospital C'" (pregnant, multiparous, Ireland) [9].

Sub-theme 5.2: Inadequate information from healthcare providers (Moderate confidence)
Women felt there was not enough information from healthcare providers, "I think there was a lot of confusion; there was no good communication about what was happening to appointments.You weren't really sure; were they happening on the phone [telehealth], when were you going to get the call?There was very little communication.So, I always felt a bit uneasy about that…" (postpartum, primiparous, UK) [77].Some information was contradictory [60] for example, "I've found the disconnect between the information that my GP was getting and that the [hospital] was getting -they weren't getting the same" (Australia) [82].Women wanted clear information that was easily accessed by the lay person [9,16,54,61,[65][66][67][68]75].They also wanted uncertainty to be acknowledged, "it would have been useful to have some generic information that went out to women in that situation… statements from a medical professional to put people's minds at ease" (postpartum, Australia) [54].

Theme 6: Being resilient and optimistic
Many women were self-reliant and took it upon themselves to remain positive and proactive throughout the perinatal period.

Sub-theme 6.1: Self-help strategies to overcome challenges of the pandemic (High confidence)
Women developed their own strategies to find solace and support [77].When asked what advice they had for other women in similar situations, advocacy for oneself was frequently reported [66,67,70,71,77,79,81,82]. In contrast, another woman regretted not voicing her concerns, "I have naively trusted that the hospital gives me the information I need … Then I realized afterwards that there were many moms who were much angrier than me and said much more; insisted much more… and I simply did not; I regret it a bit" (postpartum, Norway) [67].
Women reported coping using different strategies, such as being outdoors and active [16,52,54], limiting news and access to social media platforms [54,69,70,81], seeking professional help [58,73], informing themselves about the virus [58,71], drawing on their own faith and religion [52,69] and self-reassurance [50,52,62].Many complied with public health restrictions, however there were some women that decided their mental health and physical wellbeing was more of a priority and broke public health restrictions to seek support from family and friends [62,66,73].Despite the challenges faced during the pandemic, some women reported high resilience, positive childbirth and postnatal experiences, and feeling empowered by their ability to overcome challenging circumstances [54,58,74].

Sub-theme 6.2: Making the most out of the positive encounters (Moderate confidence)
The lack of visitors on the postnatal ward and in homes was described by women as "pleasant", "relaxing" and a "blessing in disguise" as women were able to recover and establish undisrupted routines with their newborns [54,71,72].A commonly reported positive outcome of limiting social obligations was the ability to establish successful breastfeeding, one woman said, "I was inundated with visitors with my first child and often could not feed responsively… With my second child, there is none of that pressure and I can really see an enormous difference both is his feeding and in my mental health" (postpartum, UK) [51].Women also described health services as "peaceful", as there were fewer people in waiting rooms, appointments were quick, social distancing was enforced and use of PPE limited the possibility of transmission [16,49,71,75,81,82].

Sub-theme 6.3: Information seeking and desire for more information (Moderate confidence)
Women obtained information from official government documents, guidelines released by professional bodies, the news, social media and platforms run by professional academics [53,66,68,72,81].Reasons to seek information included: to clarify any uncertainties about risk and infection, keep up to date with COVID-19 guidelines and to be informed about changes to hospital policies [49,52,66,69,77].Even once women were provided with information, poor communication and follow up left women feeling dissatisfied [54].One woman shared advice about engaging with different information sources -"you can't just trust them -you've got to decipher through what's true and what's not… Is that actually having a positive influence on me, and my mental and physical health, or not?And if it's a no, well why am I engaging in this?" (Australia) [81].

Discussion
This QES synthesised data from 36 sampled studies on pregnant and postpartum women's experiences from high income countries during the COVID-19 pandemic.Findings were categorised under six overarching themes and 17 review findings to understand their experiences as the pandemic unfolded.Women had to navigate the transition from pregnancy to motherhood, whilst also adapting to the complexities of the COVID-19 pandemic.High to moderate confidence was placed in these review findings, indicating the strength of the evidence.
This review highlights that pregnant and postnatal women across high-income countries faced similar yet inherently unique experiences and challenges.During the pandemic, primiparous women faced moderate-tohigh prenatal stress levels, as they recounted their first pregnancy experience during a time of significant uncertainty [85][86][87].On the other hand, some evidence highlighted that multiparous women were 'adaptive' and felt 'prepared' [66,71,77].However this was not experienced universally -many experienced mothers facing difficulties [9,73,80].The COVID-19 pandemic and associated public health restrictions across high-income countries disrupted access and quality of care for many pregnant and postpartum women.
Reduced health service capacity and the transition to remote and virtual care due to pandemic restrictions have been heavily criticised [8,88].In many contexts, women had not received high quality maternity care during the pandemic and described overtly negative experiences [35,89,90].Women were unable to access usual supports, had limited birth choices and reduced postpartum care which resulted in stress and anxiety.These are clearly widespread experiences, regardless of context, and highlights some of the structural weaknesses and vulnerabilities of maternity care systems.This was evident in the findings for pregnant and postpartum women of culturally and linguistically diverse backgrounds.The lack of culturally appropriate care, including access to interpretation services, doulas and being unable to have their support person present are known to impair maternal health and wellbeing [56,63,80].These factors are key elements of respectful maternity care as they help provide information, enable women's agency and ensure emotional and social support is available [91,92].Health restrictions should not limit this service for women during times of unrest, as women and babies thrive in culturally respectful maternity services [93].We note however that CALD women continue to be an under-represented group -only three of the 36 sampled studies reported evidence specifically for CALD groups [56,63,80].The lack of diverse perspectives included in the evidence base makes it more difficult for culturally sensitive and community-responsive policies to be developed.Further research with women from diverse backgrounds are warranted to ensure they are not unduly disadvantaged in future pandemics [94].
A key finding was the reduced presence of partner and social support throughout the pregnancy and postpartum periods.Partner support and strong connections with extended support networks reduces stress and anxiety, and can be a positive influence on the woman and her experience [95][96][97].In the trade-off between the risk of transmission and spread of disease, expectant fathers and partners were frequently left out [98,99].Similarly, studies of families and partners of intensive care unit patients during the COVID-19 pandemic reported being physically and emotionally unable to support partners and families [100,101].Close family members are essential to the recovery of patients upon discharge and partners are integral to a safe and positive pregnancy, intrapartum and postpartum experience for mothers.To ensure that maternity care services can adequately respond in the future, recommendations for some degree of flexibility for women given the long-term psychosocial impact that a negative experience would have on the woman and family unit has been sought [8,87,88].
Pregnant and postpartum women's experiences were not universally negative.Another key finding in this review highlights the resilience and optimism that some women felt.Some women perceived this time as a "blessing in disguise" -referencing the ability to stay at home, having fewer disruptions to breastfeeding, and embracing newfound time as a family unit [64,66,71].Coping strategies reported in this study are supported by other evidence of protective factors against stressors of the COVID-19 pandemic [102][103][104].
Maternity care services need to continue delivering care during public health emergencies.There is no possibility of delaying or postponing care; and women require care over an extended period of time.Enforced lockdowns limited movement and fear of contracting the virus in hospitals lead to delays in healthcare seeking (e.g. when there is reduced fetal movements).The pandemic altered the provision of services and women's access to care and, as a result, some countries have reported changes to the incidences of stillbirth and preterm birth [105][106][107].
Understanding women's experiences, their preferences and satisfaction with maternity care services are essential to a safe and positive pregnancy, labour and childbirth and postpartum period.Many maternity models of care such as woman-centred and midwifery-led care places the woman at the centre of care and her experience, focusing on woman's health needs, expectations and aspirations [108,109].These models have proven to return high levels of satisfaction and are beneficial to the psychological and physiological recovery of the woman [110,111].The COVID-19 pandemic has disrupted these models of care for women who were pregnant and gave birth during the pandemic.Pressures on the maternity care system and service delivery did not facilitate the midwife-woman relationship, resulting in poorer clinical outcomes [112].Supporting women throughout their perinatal period is essential so women and their babies are able to emerge from the experience feeling prepared, safe and satisfied [113,114].
Moving forward, as maternity care systems adapt to a post-pandemic structure, considerations need to be made to ensure maternity services can adequately respond to future health crises.Our QES has shown that the impacts of COVID-19 went far beyond the direct impacts on women who were infected with SARS-COV2.All women giving birth over the pandemic, especially in the first two years, were indirectly impacted and as a result experienced a lack of autonomy during their pregnancy and childbirth, barriers to accessing face-to-face care and loss of social supports.This highlights the need to consider women's views and experiences in developing policies for future responses to pandemics or public health emergencies.
We recommend that policy makers and maternity care services should: 1) optimise care delivery to maintain face-to-face care when possible and facilitate the presence of chosen support people; 2) enhance communication channels between maternity care services and women to minimise misinformation, stress and anxiety; and 3) support social and mental wellbeing to ensure women have access to adequate social support and mental health services are well resourced.

Strengths and limitations
The rigorous and systematic methodology of this QES in selecting studies for inclusion allowed us to analyse experiences of a heterogenous cohort of pregnant and postpartum women during the COVID-19 pandemic.When we started the review, the abundance of published work of women's experiences was overwhelming, therefore strict eligibility criteria were used to ensure that findings could be obtained and compared across studies.This study was therefore limited to experiences of women in high-income countries and cannot be generalised to lowand middle-income countries.
Studies were subject to a sampling framework to ensure that a diverse, yet data rich sample of studies contributed to the development of review findings.This had its own set of limitations as the sampling framework is not a validated tool and may be biased by the user's own interpretation.Additionally, the search strategy was limited to the first two years of the pandemic.While it is possible research was published outside of this two-year period, we felt that it was unlikely that different experiences would be reported.An updated search (December 2022) was conducted to determine if any new themes emerged, however no new themes emerged and therefore did not warrant the addition of any new studies.Almost all studies that used interviews to collect qualitative data did so via remote methods.Telephones and video conferencing tools were popular methods to conduct interviews, adhering to social distancing guidelines.Whilst this increased accessibility for participants from diverse geographical locations, there may be concerns about the depth of data obtained and exclusion of participants that are unable to access these technologies.A further consideration is the limited number of studies exploring the experiences of women from diverse backgrounds.This prevented us from more critically examining what factors and circumstances shape women's experiences and responses.

Conclusion
Women's pregnancy and postpartum experience during the COVID-19 pandemic showcased similarities despite different contexts.This QES has collated the experiences of women from high income countries sharing insight into the challenges faced and resilience of pregnant and postpartum women.The COVID-19 pandemic has exacerbated many systemic shortfalls of the maternal and newborn health system -a system that is essential to the health and wellbeing of women and babies.The review findings have highlighted areas within this period where strategies to inform policy and practice could be optimised to allow for better access to care and support for women in their journey to motherhood.Future pandemic preparedness strategies need to maximise face-toface care, optimise communication channels to combat misinformation and anxiety, include a flexible approach to public health restrictions for women and their families by allowing formal and informal support networks to be readily available and accessible, and to ensure maternal mental health is a priority.

Fig. 1
Fig.1Reporting of adapted PRISMA flowchart of included and sampled studies in accordance with PRISMA and ENTREQ guidelines[33] Qualitative studyAim: to explore the experiences of pregnancy, childbirth, antenatal and postnatal care in all women belonging to ethnic minority communities and to identify any specific challenges that these women faced during the SARS-CoV-

Table 1
[45]ling framework -using data richness as an indicator of quality, adapted from Ames et al. 2019[45]

Table 3
Overarching themes, sub-themes and coding tree

Table 4
Summary of qualitative review findings table including GRADE-CERQual assessment of confidence